Provider Demographics
NPI:1902474190
Name:MANTACHIE PHARMACY LLC
Entity Type:Organization
Organization Name:MANTACHIE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SPRADLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-282-7000
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:MANTACHIE
Mailing Address - State:MS
Mailing Address - Zip Code:38855-0096
Mailing Address - Country:US
Mailing Address - Phone:662-282-7000
Mailing Address - Fax:
Practice Address - Street 1:3309 HIGHWAY 371 N
Practice Address - Street 2:
Practice Address - City:MANTACHIE
Practice Address - State:MS
Practice Address - Zip Code:38855-7267
Practice Address - Country:US
Practice Address - Phone:662-282-7000
Practice Address - Fax:662-282-7007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy